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PHILIPPINE COPYRIGHT 2004 Published by Philippine Practice Guidelines Group in Infectious Diseases (PPGG-ID)

ISBN 971-92130-4-3 This guideline is intended for use by health care professionals including medical specialists, clinical practitioners, nurses, administrators and policy makers. All rights reserved. No part of this publication may be reproduced in any form without prior permission from the PPGG-ID Philippine Society for Microbiology and Infectious Diseases No. 116 9th Avenue, Cubao, Quezon City 1109 Philippines Citation as to source is suggested in the following format: Philippine Clinical Practice Guidelines on the Diagnosis, Empiric Management And Prevention of Community-acquired Pneumonia in Immunocompetent Adults 2004 UpdateJoint Statement of the Philippine Society for Microbiology & Infectious Diseases Philippine College of Chest Physicians Philippine Academy of Family Physicians

Printed by Zurbano Publishing & Printing Corp. 2195 Primo Rivera Street, Brgy. La Paz Makati City

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PHILIPPINE CLINICAL PRACTICE GUIDELINES ON THE DIAGNOSIS, EMPIRIC MANAGEMENT AND PREVENTION OF COMMUNITY-ACQUIRED PNEUMONIA IN IMMUNOCOMPETENT ADULTS 2004 UPDATE

Joint Statement of PSMID PCCP PAFP

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TASK FORCE ON COMMUNITY-ACQUIRED PNEUMONIA Vilma M. Co, MD Myrna T. Mendoza, MD Ma. Lourdes A. Villa, MD Abundio A. Balgos, MD Joselito R. Chavez, MD Jennifer A. Chua, MD Manolito L. Chua, MD Remedios F. Coronel, MD Raquel Victoria M. Ecarma, MD Benilda B. Galvez, MD Manuel C. Jorge, MD Policarpio B. Joves, MD Isaias A. Lanzona, MD Ma. Bella R. Siasoco, MD Maribel B. We, MD PSMID PSMID PSMID PCCP PCCP PSMID PSMID PSMID PSMID PCCP PCCP PAFP PCCP PCCP PSMID Chair Co-Chair Rapporteur Member Member Member Member Member Member Member Member Member Member Member Member

Thelma E. Tupasi, MD, FPSMID Adviser PANEL OF EXPERTS PSMID Angeles Tan-Alora, MD Mediadora C. Saniel, MD Thelma E. Tupasi, MD Roberto A. Barzaga, MD Teresita S. de Guia, MD Camilo C. Roa, Jr., MD Cynthia L. Hipol, MD Zorayda E. Leopando, MD Reynaldo A. Olazo, MD Emmanuel D. Almasan, MD

PCCP

PAFP

PCR

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TABLE OF CONTENTS

Foreword ........................................................................................ Methodology .................................................................................. Introduction .................................................................................... Issues and Recommendations ....................................................... 1. Can CAP be diagnosed accurately by history and physical examination? ......................................................... Table 1. Accuracy of history and physical examination for the diagnosis of CAP .............................................. Table 2. Accuracy of predicting pneumonia by physicians clinical judgment ..................................................... 2. What is the value of chest x-ray in the diagnosis of CAP? Table 3. Chest radiographic findings which may predict a complicated course .................................. 3. Which patient will need hospital admission? ................... Table 4. Clinical features of patients with CAP according to risk categories ..................................................... Figure 1. Algorithm for the management-oriented risk stratification of CAP in immunocompetent adults .. 4. What microbiologic studies are necessary in CAP? ...... Table 5. Diagnostic tests for M. pneumoniae, C. pneumoniae, and L. pneumophila .................. 5. What initial antibiotics are recommended for the empiric treatment of CAP? ............................................................... Table 6. Empiric antimicrobial therapy in CAP .................... Table 7. Usual recommended dosages of antibiotics in 50-60 KBW adults with normal liver & renal functions ........................................................ Table 8. Rank order of etiologic agents of CAP .................. Table 9. Resistance rates of S. pneumoniae ...................... Table10. Resistance rates of H. influenzae ........................

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10 12 13 13 14 15 16 18 19 22 23 24 25 27 28 28

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6. How can response to initial therapy be assessed? ........ Table 11. Indications for streamlining of antibiotic therapy .... Table 12. Antibiotic dosage of oral agents for streamlining or switch therapy ................................................... Table 13. Duration of antibiotic use based on etiology ........... Table 14. Recommended hospital discharge criteria .............. Table 15. Benefits of intravenous to oral sequential antibiotic therapy ..................................................... 7. How can CAP be prevented? ............................................. Table 16. Recommendations for pneumococcal vaccination Table 17. Recommendations for influenza vaccination ......... Reference ...................................................................................... Appendices .................................................................................... Acknowledgment ...........................................................................

29 30 30 31 31 33 34 36 37 41 51 54

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FOREWORDSince the Philippine Clinical Practice Guidelines on the Diagnosis, Empiric Management and Prevention of Community-acquired Pneumonia (CAP) was published in 1998, new developments in communityacquired pneumonia have emerged. This document aims to provide our physicians with evidence-based approach to the initial antimicrobial management of community-acquired pneumonia in immunocompetent adults. This 2004 version updates the previous guideline as it incorporates new evidence for its recommendations on the diagnosis, empiric management and prevention of CAP. The major changes that were incorporated in this document include the following: 1. 2. 3. 4. Revision of the risk stratification of community-acquired pneumonia; new criteria for admitting patients with pneumonia case; new recommended initial empiric antibiotic treatment; and updated recommendations on prevention of pneumonia.

It is important to reiterate to our colleagues that by the very nature of this guideline, it cannot encompass all eventualities. Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. Therefore, the authors, editors, and publisher of this guideline disclaim any and all liability for errors or omission or for any consequence from the application of information in this document and make no warranty, expressed or implied, with respect to the contents of this publication. Under no circumstance will this guideline supervene the experience and clinical judgment of the treating physician.

Task Force on Community-Acquired Pneumonia

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CAP Guidelines

METHODOLOGYThe evidence-based approach and formal consensus techniques (nominal group technique and the Delphi technique) employed in this years update was similar during its initial development. This include the initial phase on preparation of the evidence-based report (EBR) followed by the preparation of the interim report (IR) which is the result of review, discussion of the EBR and consensus of the group. Consensus was defined as 70% of votes cast, either by written ballots or by raising of hands. The third phase was the preparation of the draft guidelines (DG) which is the result of expert panel review of the IR. This year, the draft of the revised guideline was presented in different convention meetings of different specialties with the intention of soliciting comments, suggestions and opinions from the other specialists and practitioners. 2003 Annual Convention of the Philippine Society for Microbiology and Infectious Diseases (PSMID) 2004 Annual Convention of the Philippine Academy of Family Physicians (PAFP) 2004 Annual Convention of the Philippine College of Chest Physicians (PCCP) 2004 Annual Convention of the Philippine College of Physicians (PCP) and the 2004 Annual of the Philippine Medical Association (PMA)

The same DG was forwarded to the offices of the following organizations [American College of Chest Physicians Philippine Chapter (ACCP-PC), Critical Care Nurses Association of the Philippines (CCNAPI), Philippine Academy of Family Physicians (PAFP), Philippine Academy of Medical Specialist (PAMS), Philippine College of Chest Physicians (PCCP), Philippine College of Emergency Medicine and Acute Care (PCEMAC), Philippine College of Physicians (PCP), Philippine College of Radiology (PCR), Philippine Medical Association (PMA), Philippine Nurses Association (PNA), Philippine Society for Microbiology and Infectious Diseases (PSMID), Inc., Philippine Tuberculosis Society, Inc. (PTSI)], institutions [Armed Forces of the Philippines Medical Center (AFPMC), Cebu Institute of Medicine (CIM), Davao Doctors Hospital (DDH), Department of Health (DOH), Iloilo Doctors Hospital (IDH), Lung Center of the Philippines (LCP), Makati Medical Center (MMC), Perpetual Help Medical Center (PHMC), Philippine Heart Center (PHC), Research Institute for Tropical Medicine (RITM), San Lazaro Hospital (SLH), Santo Tomas University Hospital (STUH), St. Lukes Medical Center (SLMC), University of the Eat Ramon 8

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2004 UpdateMagsaysay Memorial Medical Center (UERMMMC), University of the Philippines Philippine General Hospital (UP-PGH), Veterans Memorial Medical Center (VMMC)], and pharmaceu